Mechanical Ventilation

EMS Professions
Temple College
 Indications

● Prolonged positive pressure ventilation

● Increased work of breathing
 Goals

● Increase efficiency of breathing

● Increase oxygenation

● Improve ventilation/perfusion relationships

● Decrease work of breathing

 Types of Systems

● Negative Pressure Ventilator

• “Iron lung”
• Allows long-term ventilation without
artificial airway
• Maintains normal intrathoracic
hemodynamics
• Uncomfortable, limits access to patient
 Types of Systems

● Positive Pressure Ventilator

• Uses pressures above atmospheric
pressure to push air into lungs
• Requires use of artificial airway
• Types
• Pressure cycled
• Time cycled
• Volume cycled
Positive Pressure Ventilators

● Pressure Cycled
• Terminates inspiration at preset pressure
• Small, portable, inexpensive
• Ventilation volume can vary with changes in
airway resistance, pulmonary compliance
• Used for short-term support of patients with no
pre-existing thoracic or pulmonary problems
Positive Pressure Ventilators

● Volume cycled
• Most widely used system
• Terminates inspiration at preset volume
• Delivers volume at whatever pressure is required
up to specified peak pressure
• May produce dangerously high intrathoracic
pressures
Positive Pressure Ventilators

● Time cycled
• Terminates inspiration at preset time
• Volume determined by
•Length of inspiratory time
•Pressure limit set
•Patient airway resistance
•Patient lung compliance
• Common in neonatal units
 Volume-Cycled Ventilator Modes

● Controlled Mechanical Ventilation

• Patient does not participate in ventilations
• Machine initiates inspiration, does work of breathing,
controls tidal volume and rate
• Useful in apneic or heavily sedated patients
• Useful when inspiratory effort contraindicated (flail chest)
• Patient must be incapable of initiating breaths
• Rarely used
 Volume-Cycled Ventilator Modes

● Assist Mode
• Allows patient to control ventilator rate
within limits
• Inspiration begins when ventilator senses
patients inspiratory effort
 Assist Mode

● Assist/Control (A/C)
• Patient triggers machine to deliver breaths but
machine has preset backup rate
• Patient initiates breath--machine delivers tidal volume
• If patient does not breathe fast enough, machine takes
over at preset rate
• Tachypneic patients may hyperventilate dangerously
 Assist Mode

● Intermittent Mandatory Ventilation (IMV)

• Patient breathes on own
• Machine delivers breaths at preset intervals
• Patient determines tidal volume of spontaneous
breaths
• Used to “wean” patients from ventilators
• Patients with weak respiratory muscles may tire
from breathing against machine’s resistance
 Assist Mode

● Synchronized Intermittent Mandatory

Ventilation (SIMV)
• Similar to IMV
• Machine timed to delay ventilations until end of
spontaneous patient breaths
• Avoids over-distension of lungs
• Decreases barotrauma risk
 Positive End Expiratory
Pressure (PEEP)
● Positive pressure in airway throughout expiration
● Holds alveoli open
● Improves ventilation/perfusion match
● Decreases FiO2 needed to correct hypoxemia
● Useful in maintaining pulmonary function in non-
cardiogenic pulmonary edema, especially ARDS
 Positive End Expiratory
Pressure (PEEP)

DANGERS
● High intrathoracic pressures can cause decreased
venous return and decreased cardiac output
● May produce pulmonary barotrauma
● May worsen air-trapping in obstructive pulmonary
disease
 Continuous Positive Airway
Pressure (CPAP)

● PEEP without preset ventilator rate or volume

● Physiologically similar to PEEP
● May be applied with or without use of a
ventilator or artificial airway
• Requires patient to be breathing spontaneously
• Does not require a ventilator but can be performed
with some ventilators
 High Frequency Ventilation (HFV)

● Small volumes, high rates

● Allows gas exchange at low peak pressures
● Mechanism not completely understood
● Systems
• High frequency positive pressure ventilation--60-120
breaths/min
• High frequency jet ventilation--up to 400 breaths/min
• High frequency oscillation--up to 3000 breaths/min
 High Frequency Ventilation (HFV)

● Useful in managing:
• Tracheobronchial or bronchopleural fistulas
• Severe obstructive airway disease
• Patients who develop barotrauma or decreased
cardiac output with more conventional methods
• Patients with head trauma who develop increased
ICP with conventional methods
• Patients under general anesthesia in whom
ventilator movement would be undesirable
 Ventilator Settings

● Tidal volume--10 to 15ml/kg (std = 12 ml/kg)

● Respiratory rate--initially 10 to 16/minute
● FiO2--0.21 to 1.0 depending on disease process
• 100% causes oxygen toxicity and atelectasis in less than 24
hours
• 40% is safe indefinitely
• PEEP can be added to stay below 40%
• Goal is to achieve a PaO2 >60
● I:E Ratio--1:2 is good starting point
• Obstructive disease requires longer expirations
• Restrictive disease requires longer inspirations
 Ventilator Settings

● Ancillary adjustments
• Inspiratory flow time
• Temperature adjustments
• Humidity
• Trigger sensitivity
• Peak airway pressure limits
• Sighs
 Ventilator Complications

● Mechanical malfunction
• Keep all alarms activated at all times
• BVM must always be available
• If malfunction occurs, disconnect ventilator and
ventilate manually
 Ventilator Complications

● Airway malfunction
• Suction patient as needed
• Keep condensation build-up out of connecting tubes
• Auscultate chest frequently
• End tidal CO2 monitoring
• Maintain desired end-tidal CO2
• Assess tube placement
 Ventilator Complications

● Pulmonary barotrauma
• Avoid high-pressure settings for high-risk patients
(COPD)
• Monitor for pneumothorax
• Anticipate need to decompress tension
pneumothorax
 Ventilator Complications

● Hemodynamic alterations
• Decreased cardiac output, decreased venous return
• Observe for:
• Decreased BP
• Restlessness, decreased LOC
• Decreased urine output
• Decreased peripheral pulses
• Slow capillary refill
• Pallor
• Increasing Tachycardia
 Ventilator Complications

● Renal malfunction
● Gastric hemorrhage
● Pulmonary atelectasis
● Infection
● Oxygen toxicity
● Loss of respiratory muscle tone
 Quick Guide to Setup

● Self check and/or Calibration as needed

● Check circuit and connections
● Set Mode: Usually “Assist/Control”
● Adjust “I” time: Usually 1 second
● Set tidal volume: 10-12 ml/kg is standard
• May need to set “Flow” based on “I” time
● Set ventilatory rate: Adult 12-16/min
 Quick Guide to Setup

● Set PEEP: std 5 cm H20; max 20 cm H20

• Caution at 10 cm H20 and greater
● Set “Assist/SIMV Sensitivity”: -2 cm H20
● Set pressure alarms
● Assess patient to confirm ventilation
function
• Monitor vital signs
• Pulse oximetry (waveform)
• Capnography (waveform)